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Overactive Bladder Symptoms (OAB) cured by surgery Cerrahi ile tedavi edilen asr aktif mesane semptomlar A. Gunnemann 13. Ulusal Jinekoloji ve Obstetrik Kongresi Belek/Antalya 12.05.2015

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OLD DEFINITION OAB symptoms: -associated with the unstable bladder ( bladder contracting involuntarily during the filling phase of a cystometrogram) -detrusor hyperreflexia (if neurological disease was present) -detrusor instability (if the cause was unknown or non-neurogenic).

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CURRENT DEFINITION: The overactive bladder syndrome (OAB) is defined as urinary urgency, usually with urinary frequency and nocturia, with or without urgency urinary incontinence International Continence Society (ICS) Standardisation of Terminology of Lower Urinary Tract Symptoms and the joint ICS and International Urogynecological Association (IUGA) report on the Terminology for Female Pelvic Floor Dysfunction

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4 Treatment of neurogenic urgency incontinence: -Neuromodulation - percutaneous tibial nerve stimulation (PTNS) -bladder augmentation -Botulinium toxin injection

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Treatment of non neurogenic Urgency Incontinence (ICS): antimuscarinic and anticholinergic drugs: darifenacin, fesoterodine, oxybutynin, propiverine, solifenacin, tolterodine, trospium and Beta3 agonists None of the drugs are an ideal first-line treatment for all OAB/DO patients: treatment individualisation patients comorbidities, concomitant medications and pharmacologic profiles of different drugs. BUT large metanalyses show clearly that the drugs provide a significant benefit

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Anticholinergic therapy: do the patients take the pills prescribed Jundt et al. 2011 After 12 months at least (N = 132) 38 % (N = 51) take the drug furthermore N = 23 (17 %) continent, much improved and satisfied N = 17 only few improved und unsatisfied N = 11 not improved 62 % (N = 81) withdraw the drug

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For different reasons, stress and urge derive mainly from laxity in the vagina or its supporting ligaments, a result of altered collagen/elastin www.integraltheory.org P. Petros, U. Ulmsten 1990

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Connective tissue at the pelvic floor which can be loose and surgically be repaired (Petros) Anterior Zone (Meatus urethrae to bladder neck) pubourethral ligament hammock extraurethral ligament Middle Zone (bladder neck to anterior cervix) Arcus tendineus fasciae pelvis pubocervical fascia cervical ring Posterior Zone (posterior cervix to anal canal) uterosacral ligament rectovaginal fascia perineal body Tethered vagina: contracted vaginal scar at bladder neck

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The stretch receptors N Transient Receptor Potential channels (TRPs) in the urothelium TRPs are sensitive to pressure. They release chemicals such NO (nitrous oxide) and ATP which stimulate afferent nerve fibres (NF), smooth muscle cells (SMC) and interstitial cells (ICC). From Everaerts et al 2008 Trampolinanalogy

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STRAINING The anterior vaginal wall acts like a trampoline beneath the bladder

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DYNAMIC ANATOMY OF STRESS URINARY CONTINENCE the key role of the pubourethral ligament

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Nocturia causation - patient lying supine in bed Empty bladder-dark green enclosed by red broken lines G USL A weak uterosacral ligament ( USL) cannot support the filling bladder which is stretched downward by gravity G . Stretch receptors N Send afferent impulses to cortex perceived as urgency which wakens the patient (nocturia).

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De Boer et al. 2010

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Community-based studies NFrequency of OAB Symptoms in women with POPwithout POPRR (POP/no POP) Tegerstedt et al. 20055.48922,5 % (454)2,9 % (5.035)5,8 Lawrence et al. 20084.10336,8 % (239)9,1 % (3.799)4,0 Miedel et al. 2008 22852,0 % (223)25,0 % (44)2,1 Fritel et al. 20092.64034,4 % (96)16,2 % (2.544) 2,1 Prevalence of OAB Symptoms in Relation to Symptoms and Signs of POP In Community-Based Studies (Boer et al. 2010)

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Author:NFollow-upFrequency of OAB symptoms monthspreoperativepostoperativeRR (pre/post) Stanton et al. 1991442427,3 %4,2 % 6,5 Jrgensen et al. 1987163787,5 %63 % 1,4 Chaikin et al. 2000104740 %20 % 2,0 Nguyen, Bhatia 200138100 %36,8 % 2,7 Weber et al. 2001 822353,3 %13,3 % 7,0 Sivaslioglu et al. 2005301653,3 %13,3 % 4,0 Farnsworth 20045918,441 %15,5 % 2,6 Farnsworth 20042419,4 62,5 %21,7 % 2,9 Milani et al. 2005321750 %40 % 1,3 Salvatore et al. 2005649375,3 %16,3 % 4,6 Brubaker et al. 2006165328,1 %11,9 % 2,4 Digesu et al. 2007931262,3%17,2 % 3,7 Natale et al. 200727944,4 %14,8 % 3,0 Basu et al. 2009492,5100 %46,7 % 2,1 Li Marzi et al. 20065117,737,2 %5,8 % 6,4 Miedel et al. 20081111227,9 %18 % 1,6 Natale et al. 20082726046,7 %22,1 % 2,1 Siviasloglu et al. 2009851224,7 %2,4 %10,3 Prevalence of OAB Symptoms Before and After POP Surgery without Concomitant Incontincene Surgery (de Boer et al. 2010)

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Petros 2009

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Tissue Fixation System Symptomatic Results (n=71) - Time 9 months Stress incontinencen=35 (87%) Faecal incontinencen= 23 (87%) Abnormal emptyingn=53 (73%) Urge incontinence (>2/D) Nocturia (>2/N) n=36 N=47 (78%) (83%) Pelvic painn=46 (86%) Uterovaginal Prolapse(n=67) (97%) Petros 2004

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Surgical treatment of mixed and urge incontincen in women Jger W et al. 2012 (prolapse stage 4: N = 0 stage 3: N = 2: stage 2: N = 2, stage1: N 129)

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Elevate anterior/apikal N = 142 Fixation by minianchor with less tissu trauma Monofil, makroporous, lightweight (24,2 g/m 2 ) Mesh (Intelpro lite, AMS)

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VariableBaseline (N) Follow-up (N)p-Value PISQ32 (N=59) 36 (N=56)< 0,001 UIQ27 (N=142)4,7 (N=124)< 0,001 CRAIQ12,4 (N=135)2,6 (N=124)< 0,001 POPIQ19,8 (N=141)1,8 (N=124)< 0,001 PFIQ58,6 (N=139)9,1 (N=124)< 0,001 UDI (obstr./discomfort) 35,2 (N=14)6,5 (N=124)< 0,001 UDI (irritative)27,7 (N=142)8,1 (N=124)< 0,001 UDI (stress)23,9 (N=142)5,8 (N=124)< 0,001 POPDI (general)43,3 (N=142)5,8 (N=124)< 0,001 CRADI (obstructive)29,8 (N=142)9,6 (N=124)< 0,001 CRADI (Incontinence)21,8 (N=142)9,1 (N=124)< 0,001 CRADI (Pain/Irritation)21,0 (N=142)7,5 (N=124)< 0,001 Elevate anterior/apikal Symptomscores preop. and after 24 months.

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VariableProp. (N) Follow-up (N)p-Value PISQ33 (N=57)36 (N=49)< 0,001 UIQ28 (N=137)8,5 (N=112)< 0,001 CRAIQ18,3 (N=135)5,6 (N=112)< 0,001 POPIQ19,4 (N=136)4,6 (N=112)< 0,001 PFIQ65,4 (N=135)18,8 (N=112)< 0,001 UDI98,5 (N=139)29,4 (N=113)< 0,001 POPDI123,8 (N=139)37,6 (N=113)< 0,001 CRADI111,2 (N=139)42,7 (N=112)< 0,001 Elevate posterior/apikal Symptomscores preop. and after 24 months

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PFDI-question 18 Do you usually feel a strong urge to void your bladder ? 35,2 % 70,0 % 71,3 % P < 0,01

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Nocturia cure rates after reconstruction of apical descent Patients with Nocturia Patients cured AuthorFollow-upNN%p Petros 20089-21 m4739 83 %< 0,01 Inoue 20123-57 m8861 69 %< 0,01 Sivasioglu 201110-22 m3823 61 %< 0,05 Farnsworth 200312 m423481 %< 0,01

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Pessary treatment for pelvic organ prolapse and health-related quality of life: a review Lamers BHC, Broekman BMW, Milani AL. Int Urogynecol J 2011;22:637-644

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Folie - 26 - Cystocele

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Folie - 27 - simulated operation by inserting a tampon (temporary pessary)

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Summary Urge incontinence can be caused by pelvic organ prolapse Surgery can cure female urge incontinence in up to 80 % by careful anatomical pelvic floor reconstruction Special case: Tethered vagina Syndrom

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31,6 % 71,7 % 72,0 % 72,7 % PFDI Question 17: do you urinate usually very often ? P < 0,01

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PFDI question 19 Do you loose urine while have a strong feeling of urgency? 42,7 % 74,1 % 75,7 % 75,6 % P < 0,01

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PFDI question 27 Does urgency wake you up during the night? 31,0 % 58,3 % 57,4 % 55,8 % P < 0,01